OPPORTUNITIES IN THE FIELD OF NURSING BY ISABEL MAITLAND STEWART, R.N., A.M. Assistant Professor, Department of Nursing and Health, Teachers College, Columbia University, Nem York City Published by The Committee on Nursing of the Council of National Defense , By permission of the Nursing and Health Branch of the Alumni Association, Teachers College Columbia University City of New York 1917 This pamphlet is in its 2Sth thousand and this edition brings it up to the 3Sth thousand PREFACE There probably never was a time when so many young women were so sincerely anxious to make their life-work count for something worth while. The thoughtful girl or woman is not satisfied any more with simply an easy job, or a situation that brings in an immediate money return. She wants something that will stir her interests, that will develop her latent ability, and will give her a chance to contribute something to the real work of the world. This is particularly true since the war has brought home to us so forcibly the need for utilizing every available talent and all the energy and devotion we possess in some definite, productive, form of national service. Nursing is probably the most vital and satis¬ fying form of service which any woman can render in critical times such as these, and it will be just as much needed in the period of reconstruction that will come after the war. The purpose of this pamphlet is to give all the main facts about the profession as clearly and impartially as possible, and to advise those who intend to fit them¬ selves for this work how best to proceed. Those who are engaged in the nursing profession and know it most intimately, do not hesitate to commend it to your serious consideration, believing that in breadth and variety of opportunity, in possibilities of service, and in positive human interests, no profession of the present day offers larger returns to the educated woman. Opportunities in the Field of Nursing Development of the Profession The story of the birth of our modern pro¬ fession of nursing reads more like a romance than a history. Everybody is familiar with the picture of the crowded hospital barracks of the Crimea, the lack of proper food and proper care, the dreadful harvest of death from wounds and cholera — then the change that came with the arrival of Florence Nightingale and her little band of nurses, when the “ charnel-house of misery ” became a decent, safe, well-managed home for sick people. The spectacular reduction in the death rate, which went down from between thirty and fifty to about two percent, was not the only proof of the value of intelligent and skillful nursing. Those refined and capable women had brought with them a new atmosphere, a new sense of com¬ fort and security, a new measure of efficiency in the management of such institutions, that broke down at last all the unreasoning and bitter oppo¬ sition which had met them in the beginning of their work. The rough hospital orderly, the poor old incompetent drudge, and the devoted but un¬ skilled amateur were alike relegated to the past, 4 so far as the expert care of sick people was con¬ cerned. The “ trained ” nurse had arrived. From the very beginning Florence Nightin¬ gale insisted on training as the only means of reaching proficiency in nursing. She had abso¬ lutely no patience with the “ born-nurse ” theory, nor with the ordinary pottering and fussing about sick-beds which well-intentioned and ami¬ able women dignified by the name of “ nursing.” To all the ardent and sometimes sentimental young women who began to volunteer their ser¬ vices for the care of the sick, she emphasized the absolute necessity of long, rigorous training. “ Nursing is an art,” she insists, “ and if it is to be made an art it requires as hard a preparation as any painter’s or sculptor’s work; for what is having to do with dead canvas or cold marble compared with having to do with the living body ? ” Again she calls it “ the finest of the fine arts.” As a public testimonial to the services of this great woman, the first nursing school was estab¬ lished in connection with St. Thomas’ Hospital, London, and from that time to the present, schools have multiplied at a very rapid rate. There are at the present time in America approxi¬ mately 1,500 schools of nursing, with a student 5 body of about 40,000. This is a larger number of students than will be found in all the medical col¬ leges of the country, and exceeds the number of women students now registered in all Ameri¬ can colleges. The work has attracted on the whole, an exceptional body of women, who have built about it the most splendid traditions of personal and public service. Though one of the youngest of the professions, it has already a strong organi¬ zation, with rapidly advancing professional standards and a considerable literature. Scope of the Field From two or three original branches, the work has broadened out till there are now from twenty to thirty fairly distinct lines of activity. From the rather limited field of the hospital and home, the nurse now goes out into streets and tenements, into shops and factories, into schools and colleges. From the more or less simple personal services to the sick, her work has developed till it includes a large number of important duties, some of them distinctively med¬ ical and sanitary, others educational and adminis¬ trative and others public and social in character. So rapid has been the expansion of this field that there has never been an adequate number of qual- 6 ified nurses to meet the need. There are probably over 100,000 nurses practising in the United States at the present time, and yet the demand for competent nurses still far exceeds the supply. All the indications go to prove that this demand will be substantially increased in the immediate future. Those who have been gauging the tendencies of the past few years say that not hundreds more, but thousands will very soon be needed, not only in homes, hospitals, and public schools, but as workers on boards of health, in philanthropic societies, in systems of education, in factories and department stores, in rural dis¬ tricts, and wherever this new idea of health con¬ servation is being actively worked out. The war has brought a greatly increased demand for nurses, not only for the care of the sick and wounded abroad, but also for the care of the sicks in camps and for the protection of workers in munition factories and other industries. It is imperative that the present forces should be sub¬ stantially increased in the near future. The scope of the work is at present practically unlimited, and the promise of really live, interesting, and useful employment is assured to all who are personally qualified and who fit themselves ade¬ quately for it. 7 Purpose and Character of Nursing Work The word “ nursing ” is a beautiful old word, meaning “ to nourish,” “ to tend,” “ to sustain or protect.” The impulse to care for those who are helpless and ailing comes from the deeply-rooted mother-instinct which all true women have in some degree. A recent author calls the nurse the “ foster-mother ” of the race. “ Wherever and whenever there is life to be tended, nourished or nursed, educated and saved, whether the life be yet unborn or new-born or senile or ill, there is the field for womanhood exercising its great function of foster-motherhood.” In a general way, the nurse in the hospital or home is responsible for the personal care of the sick person. She provides the right mental and physical environment for the patient, prevents the spreading of disease to others, carries out the physician’s instruction regarding diet, medicines, etc., assists him in operations and treatments, observes and notifies the physician of all impor¬ tant developments in the condition of the patient, and, where consultation is impossible, administers the proper medical measures as necessity arises. The nursing staff in the hospital is also respon¬ sible for organizing and administering the various services connected with the care of the sick in the 8 most efficient and economical manner possible. In some of the other branches of the work the nurse is employed mainly in anticipating ill¬ ness by identifying the early signs of trouble, in investigating unsanitary conditions, and teaching people how to prevent ill-health. In all these branches the nurse is expected to be familiar with and codperate with all the other agencies which are working toward the relief of suffering and the prevention of disease. It will be seen from this, that the nurse is not merely the assistant of the physician, though this itself is an important and very responsible func¬ tion. The nursing art is just as distinct and as specialized as the art of the medical practitioner, and is more and more recognized as such. Some¬ times it is the skill of the surgeon or physician that turns the scale in favor of recovery, and sometimes it is good nursing — one supplements the other, and both are usually necessary in any adequate care of sick people. With the increased emphasis which is being put on fresh air, good food, exercise, mental influences and occupation in the treatment of dis¬ ease, more and more responsibility is put upon the nurse, and a much higher degree of initiative and judgment is demanded of her. In many of the 9 newer branches of the profession the nurse works more or less independently, calling in the services of the medical expert only when necessary. Her duties are perhaps more distinctly social and edu¬ cational than medical, and yet she must under¬ stand the nature and causes of disease, and must be expert in the observation and handling of sick people. Training Required and How Secured It will be seen at once that such duties and responsibilities demand a very considerable degree of knowledge and skill. The sciences underlying them are varied and comprehensive, the proced¬ ures are often complicated and technical, and the power of observation required is highly special¬ ized. The ability to organize all these complex duties, to deal with all classes and kinds of people, and to meet critical situations wisely and prompt¬ ly, requires long experience and constant practise in the actual conditions of the sick-room. From lectures and text-books alone, important and essential as these are in certain phases of the training, such powers cannot be derived. These are some of the reasons why schools of nursing must be attached to hospitals, and why from two to three years’ experience in the actual 10 handling and care of sick people, under the con¬ stant eye of experts, is considered essential to ensure safety to the public and an adequate train¬ ing to the nurse. Types of Schools. Nursing schools are connected with general hospitals, (caring usually for all types of diseases and all classes of patients) and special hospitals, such as fever, maternity, surgical, tubercular, and insane hospitals, or hospitals for children, for women, etc. Generally speaking, the hospital caring for a wide range of diseases, with patients of every age, class and sex represented, and with a pretty active service, offers the best facilities for training. It is absolutely essential that the student nurse should have adequate experience in the care of medical, surgical and obstetrical cases, and in the diseases of children. Hospitals vary much in size, ranging from 15 or 25 beds up to 1,000 or 1,500, or even more. New York State and several other states require any school which is registered as a training school for nurses to be connected with a hospital of at least 50 beds. The small private or the special hospital is at a distinct disadvantage in offering a II training for nursing, unless it is affiliated with other hospitals giving experience in all branches of nursing work. Length of Training. With the developments in surgery and medi¬ cine creating a large number of new specialties and with the gradual extension of the nurse’s duties, the course of training has been extended from one to two, and later, in most of the best schools, to three years. It is found that the work cannot be covered thoroughly, and that the aver¬ age student nurse cannot get the maximum benefit from her course in less than three years. Several prominent hospitals have recently agreed to reduce the regular three-year course by from eight to twelve months, for students who have completed a full college training, including satisfactory courses in the sciences underlying nursing work. Character of the Training The work in the nursing school is both theo¬ retical and practical. In all the better schools the new classes come in at certain stated periods, and the students receive some preliminary theoretical training before they are allowed to begin their practical work in the wards. The probationary period lasts usually from two to six months, after 12 which there are examinations both in theoretical and practical work. If the results are satisfactory the applicant is retained in the school. After the probation period, she adopts the uniform of the school and enters the wards as a pupil nurse, con¬ tinuing her class and lecture work throughout the whole course. Lecture and Class Work. The time devoted to the theoretical work varies a great deal in different schools, ranging from about two to six hours per week, except in the earlier part of the course, when from ten to eighteen hours per week may be given to theo¬ retical work. The class term is usually from October to May, while the practical work extends through the year. The subjects which are studied in a nursing school vary somewhat, but usually cover the gen¬ eral sciences underlying nursing work {anatomy and physiology, bacteriology and chemistry), the household sciences {cookery and nutrition, die¬ tetics and hospital housekeeping), the study of disease in all its various branches, with the nurs¬ ing measures required in each {medical, surgi¬ cal obstetrical, children’s infectious diseases, etc.), the subjects dealing with the prevention and treatment of disease {hygiene and sanitation. 13 materia medica, massage, etc.) and certain gen¬ eral subjects which deal with the history and ethics of nursing and the social and professional aspects of the nurse’s work. The main part of the teaching is usually car¬ ried on by nurse instructors, and by specialists in the various branches represented. Physicians usually give the lectures on disease and some¬ times carry on the work in some of the sciences also. It would be a mistake to conclude that all the theoretical training is confined to the classes and lectures. A great deal of the most valuable teach¬ ing the pupil gets in the ward, over the bed of the patient, or in close touch with actual living conditions. Supervisors and head-nurses are usually at hand to direct and criticize her work, and visiting and resident physicians add their substantial contribution to her education. Technical and Executive Experience and Prac¬ tice. The practical work in the ward (the nurse’s laboratory), gives the student a chance to observe, to gain skill and facility in nursing pro¬ cedures, and to acquire confidence and control in managing herself and others. The work proceeds usually from the simpler to the more highly tech- 14 nical processes, the student spending a few months in each of the different departments of the hospital. As she gains in experience, she is promoted to positions of greater and greater responsibility, and so develops the capacity for leadership and organization, which stands her in good stead when she is cut loose from the sys¬ tematized and regular work of the hospital. Nursing Courses Connected ivith Universities. The present system of education, while giv¬ ing the student exceptional advantages in the close observation and care of sick people, pre¬ sents some limitations. It is believed that many of these would be overcome if the hospital train¬ ing school could be connected up with a good college or university where most of the funda¬ mental scientific training could be given. Such affiliations have now been established in several universities, such as those of Minnesota, Indiana, Cincinnati, California, Leland'Stanford, Wash¬ ington (St. Louis) and Columbia (New York). A combined academic and professional course of five years, leading to the Bachelor of Science Degree, is now offered by the Department of Nursing and Health, Teachers College, Columbia University, in cooperation with the Presbyterian Hospital, New York City. Students with two 15 years of work in a good college, normal or techni¬ cal school, would require only three years for the degree and nursing diploma. Similar arrange¬ ments can be made in several of the above mentioned universities. Even where a training school has no organic relationship with a nearby college or medical school, it is often able to make use of its better teaching and laboratory facilities, and so improve its work. Cost of Tuition. In a few schools a fee is charged for the pre¬ paratory course, ranging from $25 to $50. Where this preliminary course is taken in a college, the fee is of course the same that all students pay in that institution, with living expenses in addition. In most schools the student receives her tuition and living expenses (which include room, food and laundry) from the hospital in return for her services. Hospitals often make an allow¬ ance of from $4 to $10 per month for text¬ books, uniforms and incidental expenses, but many prominent schools have given up this practice, preferring to expend the money on bet¬ ter teaching facilities, better supervision, and more trained instructors. Where the instruction is excellent and the living and working conditions are good, it is believed that the pupil has a full i6 equivalent for her services, in the education received. Where these conditions do not hold, no money allowance can make up to the pupil for their lack. In several schools scholarships are offered, which are designed to assist students who prove unusually capable either in their studies or in practical work. Conditions of Work in the Hospital Effects on Health. Nursing is known to be very exacting and responsible work, but it is a great mistake to think of it as exhausting or dangerous to health. Most pupils in training find themselves in better condition physically than before they entered the hospital, and very few are injured by the work in any well-regulated hospital. The regular hours, the wholesome food, and the physical activity, as well as the unfailing interest of the work itself, help to offset any disadvantages which may come from indoor life, fairly long hours and contact with sickness. On the whole, nurses will be found to have fewer illnesses than teachers and office workers. Pupil nurses receive free medical attendance and care in illness, though the time lost must usually be made up in full. 17 Hours of Duty and Vacations. The hours of pupil nurses in most hospitals have always been too long, considering the class work and study which is expected of the students. The tendency is all toward a lowering of these hours of duty, many schools now adopting the eight-hour system. Those that still hold to a nine or ten-hour day give one free afternoon a week. Students are usually assigned to from four to eight months of night duty, in periods of from one to two months’ duration, any time during the three years. Vacations average about three weeks yearly, several prominent schools giving one month. Housing and Food. Improvements in living conditions for nurses have been very marked in recent years. Beauti¬ ful residences for the nursing staff are a feature of many modern hospitals, well equipped with class-rooms, laboratories, libraries and reception rooms. The food served to pupil nurses will com¬ pare very favorably with that found in college dormitories and boarding schools. Some schools have country and summer homes where pupil nurses are sent for change and recreation. i8 Social Life. The life in the hospital is too intense and absorbing to admit of many'outside social activi¬ ties, but the opportunities for observing and knowing all kinds of human beings of every class and type, make the possibilities of social develop¬ ment rather exceptional. It is an undisputed fact that numberless nurses look back to the years of their hospital training as the time when they met the most interesting people, formed the closest friendships, and enjoyed the happiest and most memorable experiences of their lives. The nec¬ essity for recreation and outside interest is being recognized more fully in all the better schools. Provision is being made for tennis and other out¬ door games; roof-gardens, gymnasia and swim¬ ming pools have been added to some of the newer homes, and classes in physical training and danc¬ ing are often provided. Though the hour for retiring is usually about lo; 30 P. M., permission for late leave is granted at reasonable intervals for theaters and entertainments, and in the nurses’ residence very jolly class parties, recep¬ tions and dances are not infrequent. Rules and Regulations. The regulations governing the Nurses’ Home are much the same as for any large dormitory. 19 In a number of schools the students themselves have much to do with making and enforcing all the general regulations of the home. On the wards, however, the military type of discipline is still in force, though by no means so rigidly exer¬ cised as in the old days. Where matters of life and death are at stake, the habit of prompt and implicit obedience to orders is absolutely neces¬ sary, and no one who knows the conditions to be met in hospital work, questions the necessity for the loyal co-operation and obedience of all to those in command. Outside of certain more or less well-defined limits, however, there is plenty of room for the nurse to exercise her judgment and initiative and to express her individuality. She will have ample opportunity for demonstrat¬ ing her ability to carry responsibility, to organize and direct work, and to lead and guide others. Special Interests and Satisfactions Wherever there is serious illness there will, of course, be some mental and nervous strain, but it is a mistake to imagine that acute or distressing illness is the rule in hospital wards. By far the largest number of patients are either moderately ill or on the way to recovery, and the joy of see¬ ing them daily mending under one’s care more 20 than counter-balances the depressing effects of the occasional inevitable tragedy. Probably the most inspiring part of the work is the privilege of assisting in the wonderful results which are being accomplished by the great surgeons and by other leaders in the field of research and practical medicine. The nurse’s work is a most essential part of all these activities, and so she has a vital interest in every detail con¬ nected with them. Nothing seems petty or unim¬ portant when the purpose of the whole is under¬ stood ; nothing is drudgery which ministers to the welfare of her patient. The nurse sees far more of the personal and human sideof hospital life than the physician does. She gets closer to her patients, and being con¬ stantly with them, she can help them so much more in all their various interests and needs. There is a strong pull on all that is best in a woman when she feels so many depending on her for strength and comfort, and often for life. While her responsibilities mature her, they strengthen her, and, if she is made of the right stuff, she cannot fail to be a better and more use¬ ful woman for all the experiences she has gone through. Sometimes, of course, hard things have to be met, as in all other ways of life that are 21 worth while. There is a joyful challenge in a difficult task, and a satisfaction in its performance that comes only to those who dare attempt the harder paths of duty. These subtle satisfactions nurses receive in full measure. The spectacular and sensational pictures of the hospital as depicted by the popular novelist, are rarely true to life, and yet there is much that makes a strong appeal to the imagination and the sympathies, even in the most ordinary hospital ward. Nowhere does one find more high lights and shadows, more dramatic situa¬ tions and more fascinating glimpses of human nature. There is adventure too, and heroism, and lots of healthy humor to keep the balance true. Qualifications Required in Nursing Education. To make a good nurse, one must have an alert and understanding mind, good judg¬ ment, cultured tastes and sufficient knowl¬ edge of the sound fundamentals on which a professional training can be built. No diploma is a guarantee of these qualifications, but we know that they are rarely found except among women who have had a fair amount of 22 education. The better schools of nursing accept only high school graduates. Mature women who have had exceptional experience and training are sometimes admitted on the same standing, but as a rule candidates with superior education are pre¬ ferred. College women in increasing numbers have been entering nursing schools in recent years, and even the brightest feel that they need all the resources that a college education gives, to enable them to meet the higher demands of the profession. Subjects which will prove of especial value to the prospective nurse are Biology, Bacteriol¬ ogy, Hygiene, Chemistry, Physics, Household Science (including Cookery, Nutrition and Housekeeping), Sociology, Psychology, Ethics and Economics. Latin is useful in helping to master technical terms. Modern languages are of considerable service in the hospital wards and subsequent social work. English and History are of course essential. Arithmetic is necessary, but Algebra and Geometry are of little practical value except in the study of chemistry and physics. Voice Culture is one of distinct value, while Music and Drawing, Games and Dancing, Art and Craft Work, and other accomplishments all prove serviceable in certain types of nursing. 23 Lettering is required in most schools for charting work. Students who are too young to enter a School of Nursing, are strongly advised to pursue their studies, either in high school or college, along these lines. Experience in the management of a good home, training in domestic science, in kinder¬ garten work, or teaching of any kind, experi¬ ence in social settlement work — anything that trains the eye to observe accurately and the mind to act quickly and surely; that broadens one’s outlook and develops one’s sympathies; that gives understanding and experience in the hand¬ ling of people; that trains the hands in deftness and fineness of touch; that gives one orderly and systematic habits; that enables one to pursue a given course seriously and intelligently — all these help in fitting one to be a better nurse. Character and Personality. Good nurses are not made from any stereo¬ typed pattern. Indeed, there is no profession where individuality is more needed, and where people of varying temperament and personality will find a wider range of congenial occupations. There are, however, a few essentials in consider¬ ing one’s fitness for this work. A nurse should be strong, because people will lean on her; she 24 should be truthworthy because people will confide in her; she must have a certain steadiness and self-reliance, for heavy responsibilities will some¬ times be put on her. Needless to say, she should have the spirit of service, and a sincere interest in human beings of all classes and kinds. Tact, and the right kind of sympathy, are highly important; a sense of humor, resourcefulness and adaptability one would be inclined to put among the essentials. Many other desirable quali¬ ties will be developed by the right kind of a train¬ ing. Certain types, such as the incurably lazy, sentimental, frivolous, morbid or unreliable girl, have no place in a nursing school, but on the other hand, it is astonishing what unsuspected powers may be developed and what objectionable traits may be eliminated by the demands of a serious and responsible task which requires one’s best effort. Physical Qualifications. It is important that the student nurse should have good general health, but it is a mistake to assume that nursing demands any unusual phy¬ sique or exceptional strength. Size is not a very important factor, though the well-built young woman of average height and weight is of course preferred. The age of entrance varies in 25 different schools, usually between nineteen and thirty-five years. The best age at which to begin a nursing course is from twenty-one to twenty-five years. Seventeen or eighteen years is considered too young, unless the girl is steadied and matured by unusual responsibilities, and is physically well-developed. Any deformity or weakness in feet, hands or back would be of serious disadvantage; a weak throat and chest, a bad heart, or poor hearing or vision would dis¬ qualify. Most nursing schools demand a certifi¬ cate of health from a reputable physician before a pupil’s entrance, and insist on a thorough physi¬ cal examination before accepting her. This is a protection both to the school and the student. Teeth and eyes should be attended to before entering the hospital, and one should enter in the best possible physical condition. Positions and Remuneration The field of nursing, as already stated, is expanding at a very rapid rate. In no other pro¬ fession for women is there such a wide variety of positions to choose from. Private nursing is undoubtedly the most familiar field to the general public, but it does not represent at all adequately the possibilities open to progressive women in the field of nursing today. Women of exceptional 26 executive ability usually choose institutional or administrative positions; those who are inter¬ ested in the educational and scientific phases of the work become superintendents, teachers or technical assistants. The woman whose inter¬ est is centered in the human and social side of nursing has a large number of fields to choose from. Some of these positions are briefly described below, with the salaries that may usually be expected in them. Private Nursing. The work of the private nurse may be either in the home or the hospital, where she will be responsible for the bed-side care and treatment and the general welfare of individual sick patients. Of recent years there has been a demand for specialists in private nursing who are qualified to give expert care in certain classes of disease, such as children’s diseases, mental and nervous diseases, maternity work, etc. The hours of pri¬ vate duty are usually long and the life somewhat exacting. The interest of the work varies much with the personality of the patient and the acute¬ ness of the disease. Opportunities for travel and the very interesting experiences of social life among all classes of people are felt to be some compensation for the lack of personal freedom 27 when on actiA^e duty. Between cases the private nurse is absolutely free, and her vacations are usually at her own disposal. Salaries for private nurses vary in diflferent parts of the country. The minimum for general cases is usually from $20 to $28 per week, while the specially trained and experienced woman may receive from $30 up for her services. It must be remembered, however, that cases are often short, and sometimes exhausting, and there is a good deal of time when the private nurse cannot be actively employed. The average yearly income of the private nurse is believed to be about $900. When on duty she receives her living, but she has a room always to keep up, and she must pro¬ vide for her living expenses when off duty. In the larger centers, there are always a few posi¬ tions where nurses are engaged from year to year in wealthy families. Others do hourly nursing, which means that the nurse lives in her own home and is called out much as a doctor is, to assist in operations, give special treatments, etc., for which she is paid by the hour. The number of private nurses is usually fairly adequate in cities, though towns and country districts often suffer for lack of good nurses. A competent private nurse of agreeable 28 personality is, however, practically sure of con¬ stant employment. She usually joins a nurses’ registry, which keeps her in touch with physicians and the public. Hospital and Training School Positions. Positions in hospitals, sanatoria, etc., may be those of superintendent, assistant superintendent, supervisor, head-nurse, operating room nurse, matron of nurses’ home, dietitian, etc. Officers of training schools are usually considered also as officers of the hospital, but they are more specific¬ ally concerned with the education of the nurses. Very often in smaller institutions the positions of superintendent of hospital and training school are combined. The position of superintendent of a nursing school is usually comparable in dignity and importance with that of dean of a small college or principal of a school. The instructor of nurses usually gives her whole time to class work, and occupies much the same kind of a posi¬ tion as that of instructor in any professional or technical school, except that she usually lives in the hospital. A few positions as visiting instructor are opening up, and several teaching positions in universities are now available. Posi¬ tions as dietitians and housekeepers in hospitals are also open to qualified nurses, and there is an 29 increasing demand for nurses with special train¬ ing in these branches. The technical specialties in the hospital include the work of the operating-room nurse, the nurse anesthetist, the assistant in electro¬ therapy and X-Ray work, the expert in massage, hydrotherapy and mechano-therapy, and the lab¬ oratory assistant. The last-mentioned fields are not so common, but the demand for nurses in them is increasing. A new branch of institu¬ tional work where nursing training is a distinct asset, is that of occupations for invalids. Several nurses are now employed as teachers of occu¬ pation therapy. For most of these executive teaching and technical positions, additional training and experience outside of the regu¬ lar hospital course, while not as yet com¬ pulsory, is very advisable. The Department of Nursing and Health in Teachers College, Columbia University, offers advanced courses to graduate nurses who wish to fit themselves for executive and teaching posts, as well as for the fields of Public Health Nursing. Salaries of superintendents vary from about $ioo to $250 per month, the average probably being about $100 per month. Assistants, anaes¬ thetists and dietitians receive from about $50 30 to $100 per month, averaging about $75; head nurses get from $40 to $60 and instructors from $75 to $100. All institutional posi¬ tions include room, board and laundry unless specified to the contrary. There is a steady demand for good institutional workers, especially for women of broad education and experience, of good administrative ability, and forceful person¬ ality. Ptiblic Health Nursing. This term includes a number of varying activities, all of which are definitely concerned with public health and social betterment. It is largely preventive and educational work though it also concerns itself with the personal care of the sick in the home. District or visiting nursing is the oldest of these branches, and all the other activities may be said to be ofif-shoots or special forms of district nursing. Some of these visiting nurses are primarily devoted to the care of mothers and small babies; some to mental and nervous patients; others to tuberculous patients, etc. Infant zvelfare zvork includes the actual care of sick babies as well as the teaching of mothers. It is carried on in the homes, in schools, in dispen¬ saries, milk stations, fresh air camps, etc. Com¬ bined with it or existing as a special branch is 31 prenatal nursing, which deals with the care and teaching of expectant mothers. Insurance nurs¬ ing differs only in that the nurses are paid by the insurance companies for visiting industrial policy holders who are sick and helping to keep them well. If health insurance becomes compulsory as it may in a few years, this branch of nursing would be tremendously increased. Visiting nursing in rural districts and small tozvns, combines all these types of work and often includes school nursing as well. Rural nurses often join The Town and Country Nursing Ser¬ vice of the Red Cross, which carries this work into the more remote pioneer districts, as well as the better-populated sections of the country. A similar service in country districts is often carried on by State Boards of Health, and private organi¬ zations. In all these branches of public health nursing directors and organizers are paid from about $ioo to $150 per month, usually without living expenses. The general worker receives usually from $60 to about $85 per month. A few posi¬ tions as directors and instructors in schools for public health nurses are available, the salaries being much the same as for superintendents. 32 Social Service and Welfare Work. This work differs from the preceding only in that there is usually less actual nursing done, and the positions are open to other workers besides nurses. Hospital social service aims to conserve the patient’s strength while he is in the hospital and after he leaves, by attending to home condi¬ tions, getting him the right kind of employment, securing proper food, and putting him into rela¬ tions with agencies which will help him. Welfare work in department stores and factories is speci¬ ally designed to improve sanitary conditions, to advise and teach employees how to keep well, to see that they get proper attention when sick and to render first aid in accidents. Nurses are preferred in all of these positions if they have the other essential qualifications. The salaries are from about $75 to $125, without maintenance. Philanthropic societies, specializing in Child Welfare, Mental Hygiene, Red Cross, Tubercu¬ losis work, etc., often secure the services of nurses as secretaries for organization and pub¬ licity work. The salaries offered are usually from $100 to $200 per month. Other lines of social activity in which nurses have proven themselves successful are sanitary inspection, sanitary inves- 33 tigation, zvork zjuith defectives and criminals, police matron zvork, and probation zvork. School Nursing. This is an extension of visiting nursing, but it is fast becoming a distinct branch by itself. Its activities lie in both the school and the home, and the opportunities for educational and preventive work are very great. School nurses usually receive from about $75 to $100 per month, with¬ out living expenses. The hours are shorter, how¬ ever, and the duties are not so heavy as in some other branches of nursing. Resident nurses in hoarding schools and colleges have more actual nursing to do, and are often expected to teach hygiene in the class-room as well as to individual students. The hours are usually long and the duties rather exacting, but these conditions will doubtless be remedied as the work becomes better organized. Salaries range from $50 to $100 with maintenance. O ffice Nurse and Laboratory Assistant. Physicians, surgeons and dentists often employ nurses as assistants in their office prac¬ tise. They prepare for examinations and oper¬ ations, do routine bacteriological examinations, give electrical treatments, massage, etc., and gen- 34 erally assist the physician. "Salaries vary much — generally from $6o to $ioo per month, without maintenance. Nurses are also employed in bacteriological and research laboratories. Salaries here are usually $25 to $100 per month. Army, Navy and Red Cross Nursing. Nurses who enter the army and navy service in times of peace are detailed to one of the regu¬ lar army or navy hospitals, where their work is somewhat similar to that in civilian hospitals. They are an integral part of the army or navy personnel, and are under the same general regu¬ lations as other members of those forces. In times of war, they serve either in the field or in the base hospitals at home. The salaries range from $60 to $100 per month, including main¬ tenance. Red Cross nurses are graduate nurses who are regularly occupied in other fields of work, but who have enlisted with the American Red Cross nursing service for emergency duty in event of war or other national calamities. They are pledged to respond at any time to the call of the Red Cross, for service either at home or abroad. When the country is at war, the various nursing corps are first recruited by the Red Cross 35 and then transferred to the regular army or navy medical service. Only thoroughly qualified nurses from registered hospitals are accepted for the Red Cross nursing service. Salaries range from $6o per month up, including maintenance. Nursing in Home and Foreign Mission Fields The work is really very much the same here as district and hospital work at home. The scarc¬ ity of nurse volunteers has seriously handicapped the work in many of the foreign posts, and women who have had this training will always be eagerly welcomed. Salaries vary much with dif¬ ferent countries and conditions, but is usually on the .same basis as other missionary helpers. The most thrilling tales of pioneer work among the mountain Avhites of North Carolina, and the fish¬ ermen of labrador rival anything that has been told of the far-oflf fields. Here also the need is very great. Opportunities for Advancement and Future Development In addition to these fields which have been more or less clearly marked out, there are a num¬ ber which offer opportunity for pioneer effort. The whole field of mental and insane work is calling for expert nurses; almshouses must also 36 be reclaimed from the hands of ignorant and untrained workers ; occupational work for mental patients and for the physically handicapped needs to be developed and scientifically studied; and the work of the foreign midwife must be improved and possibly replaced by a more satisfactory ser¬ vice. Many other branches of public welfare work are waiting for investigation and organiza¬ tion. The problems are all extremely practical and vital to public welfare. The nursing body has done much, but it needs reinforcements. The system of education in nursing is itself under¬ going radical changes and particularly calls for educated women. Any one of these problems offers scope for the highest kind of intellectual and administrative ability that can be secured. It will be seen from the foregoing that there is no lack of opportunity for the right kind of women. Especially are needed leaders, who, in addition to wide culture, and excellent profes¬ sional training, have the capacity for enthusiastic, whole-hearted, constructive effort. No one will succeed who is afraid of work. Experience shows that wherever women have demonstrated their fitness for superior service, salaries have usually risen to meet them. Fortunately, most of the good women in nursing regard salary as a second- 37 ary matter. The main thing is the opportunity for real service, and this is positively unlimited. Nurses are founding settlements, directing phil¬ anthropies, organizing local and national health movements, occupying positions on the most in¬ fluential committees, teaching in colleges, editing magazines, lecturing — indeed there are almost no fields of public service in which they are not en¬ gaged, and in which they may not aspire to serve. Advantages Over Other Vocations for Women Compared with other professions for women, nursing has many advantages. Almost from the beginning the pupil nurse is engaged in real living problems, not merely in an abstract preparation. The training requires no large financial outlay, her services covering expenses of tuition and to a great extent expenses of living as well. She does not have to face the competition from men which meets women in every other profession, and so far there has been little competition among nurses themselves. The day she graduates the nurse may usually begin her work, without searching for a position or waiting for a tardy practise to grow up. She requires no expensive outfit to keep up, and so long as health lasts, she has an assured income. She need not remain in any fixed place, for wherever she goes, if she is a 38 competent woman, she is likely to find some demand for her services. If she wishes to go into any other fields of work, her nursing train¬ ing is always a valuable asset. In times of war and national calamity, it places her in the first line of defense and enables her to render probably the most valuable service it is in the power of any woman to give to her country. The great objection raised to many of women’s occupations is that they unfit, or at least do not help in fitting a young woman for her probable future as a homekeeper and a mother. Nursing is the best possible preparation for these vocations. It gives training in management, in cookery and dietetics, in sanitation and the care of children, and in many other branches which are of distinct value in the keeping of a home. In addition nurses have abundantly shown that their unusual opportunities for knowing human nature and observing social problems, and their practical grasp of effective measures, make them especially valuable citizens in any community. From these points of view, one would be inclined to recommend the training for almost all women. In a recent address by Lady Helen Monroe Ferguson on “ The Nurse as a Citizen ” she con¬ gratulates nurses on the fact that their horizon. 39 instead of being narrowed, is constantly being set farther back, and that their work, instead of tending to contraction of character and impover¬ ishment of soul, tends to bring into play every quality which they possess. The possibilities of social usefulness and of self-development are limited only by their own capacity. This cannot be said of a great many other occupations. Suggestions for Entering the Nursing Profession There is no way of becoming a recognized member of the nursing profession except through graduating from a good training school. The cheap, short-cut methods have all proven futile and deceptive. Correspondence courses can no more train one to be a nurse than they can train a soldier or the captain of a vessel. The results of ignorance might not be so great in an occupa¬ tion like stenography, or an art like music or painting; but where they are disastrous to life and human welfare, ignorance and incompetence become little less than criminal. Just as in medicine or any other pro¬ fession, the status of the nurse in the community and among her co-workers depends a great deal on the prestige of the school from which she received her training. Without a diploma from a 40 reputable school, she cannot look forward to occupying any important positions, or winning the confidence of a discriminating public. The choice of a good school is thus of the highest importance. Unfortunately, we have in this country a large number of hospitals where the economic value of the work done by the pupil nurse, and not her education, is the prime and only consideration. One may get a certain kind of experience in such an institution, but no consecutive or systematized teaching. No money inducements, or low age or educational standards, should tempt anyone to enter such a school. Before making a choice, applicants should visit several schools or write making full inquiries regarding the following conditions. All good schools welcome visitors and are glad to answer inquiries about their work. Many mothers have been induced to forego their prejudices and allow their daughters to take up nursing, after a visit to a good up-to-date institution. The important points to be considered will be — Size of School and Character of Service. It is not necessary that the hospital should be a very large institution. A small hospital (not less than fifty beds) may give a good training if it connects itself with other and larger institu- 41 tions. The scope and character of the work done is of the greatest importance. Training in a loo¬ ked general hospital with an active and varied service is usually more profitable than in a much larger institution, which cares for only a few kinds of diseases, and those more or less chronic in character. Reputation. The value of a nursing school is not always directly proportioned to the prestige and reputa¬ tion of the hospital with which it is connected. Some hospitals that have built up a reputation on the work of a brilliant surgeon, or a magnificent building, give their nurses very inadequate train¬ ing. The reputation of the nursing school depends on the standards set for the actual care of the patient and the training of the nurse. Standards of Entrance. If there are no educational requirements at all, or if they are very low, it is fair to draw the conclusion that the educational work is not of a high character. Most of the better schools demand a high school certificate or its equivalent. If one cannot meet this moderate standard, it is usually better to make good one’s deficiencies rather than enter the school which has lower 42 standards of education. High schools, evening schools and special courses, enable any ambitious woman to meet these educational requirements. The Course of Study. Though lectures and classes are not the all- important thing in a nurse’s training, they are a pretty fair indication of the standards which the school considers important. A few unrelated, unsystematized lectures by even the ablest physi¬ cians will never take the place of systematized and continuous teaching by the nursing staff. The extent of this class teaching and the thoroughness with which it is organized is a fair measure of the efficiency of a school. The Character and Capacity of the Teaching Staff. It is impossible to too strongly emphasize this point, for the school to a great extent takes its tone, not from the physicians and the board of managers, but from the principal of the school and her assistants. Well-educated, broad-minded, progressive women at the head, will make up for a great many deficiencies; and though no degree or title can guarantee these things, nurses them¬ selves place greater reliance on those who can put R. N. after their names. (See p. 44.) If, 43 in addition, a superintendent or teacher has had large experience in important posts or has taken postgraduate work to fit her better for her posi¬ tion, a better quality of teaching is usually insured. Living and Working Conditions. These are important considerations, for one’s health and efficiency depend to such a great extent on them. Any school that still holds to a ten or twelve-hour working day, and a one or two weeks’ vacation, need not expect to receive appli¬ cations from discriminating women. A number of schools still send their pupils out on private duty during their course of training, the hospital receiving certain remuneration for their services. The best authorities in the nursing profession feel that this is a profound injustice to the pupil nurse, since it interferes with her course of study, removes her from the supervision of her instruc¬ tors and greatly limits her opportunity for obser¬ vation and practise. Standing of the Alumnae of the School. This is also a fair test of the value of a train¬ ing. If former pupils are occupying prominent positions all over the country, if they are repre¬ sented in professional organizations and in public 44 and social enterprises, the school is likely to have good traditions of training'. Registration. It would be wise for all intending applicants to inquire whether the school they think of enter¬ ing is registered in its state, and whether its grad¬ uates are eligible to the title of Registered Nurse (R. N.). Owing to the united efforts of nurses, laws have been passed in most of the states for the purpose of upholding good standards of edu¬ cation, and giving the public some means of determining the qualifications of women practis¬ ing as nurses. Schools which meet certain mini¬ mum requirements are allowed to register. Their graduates only are eligible for the state examina¬ tion, and for the certificate which the state gives. In a few states, no one may practise as a nurse who does not pass this examination, and the like¬ lihood is that very soon such compulsory regis¬ tration will be general. Already several large organizations employing nurses (such as the New York Board of Health and the National Red Cross Society) have decreed that they will receive applications only from registered nurses, and practically all the professional organizations re¬ quire this qualification (where such laws are in force) for membership. While registration either 45 of hospital or nurse, is not to be regarded as a testimonial of high efficiency, it shows that cer¬ tain fundamental standards have been met. If in doubt about the reputation of a school it would be wise to consult some official of the States Nurses’ Association, or to write to the edi¬ tor of a reliable nursing periodical, one or two of which are mentioned below. In the list of references below will be found much fuller discussions of the history and scope of nursing and its place in the work of the world to-day. References; Nutting, M. Adelaide, and Dock, Lavinia D.'— History of Nursing. 4 Vols., Putnams, 1907 and 1912. Cook, Sir. Edward — Life of Florence Nightingale. 2 Vols. Macmillan Co. Nightingale, Florence — Notes on Nursing — What it is and what it is not. Appleton, i860. Wald, Lillian D. — The House on Henry Street. Holt, 1915. Gardner, Mary S. — Public Health Nursing. Mac¬ millan Co., 1916. Epler, Percy H. — The Life of Clara Barton. Mac¬ millan Co., 1916. Tiffany, Francis — Life of Dorothea Lynde Dix. Houghton-Mifflin, 1896. 46 Richards, Linda — Reminiscences of Linda Rich¬ ards. Whitcomb & Barrojvs, 1911. Boardman, Mabel — Under the Red Cross Flag. Loane, M. — The Queen’s Poor, The Next Street but One, From Their Point of View, Neighbors and Friends, etc. (Contain very interesting descrip¬ tions of the experiences of a visiting nurse in Lon¬ don.) Arnold, London. Saleeby, C. W. — Surgery and Society (Chap. XIII — Florence Nightingale. Chap. XIV — The Modern Nurse). Herbert & Daniel, 1912. Nutting, M. Adelaide — Educational Status of Nursing — Bulletin of the U. S. Bureau of Educa¬ tion, No. 475, Government Printing Office, Wash¬ ington, 1912. Wald, Lillian D. — Article on Nursing in Vocations for the Trained Woman. Edited by Agnes F. Perkins and published by the Woman’s Educational and Industrial Union, Boston; also a Vocational pamphlet on Nursing, published by same organi¬ zation. Morley, Edith — Women Workers in Seven Pro¬ fessions (Sec. Ill Nursing). Routledge, 1914. Cannon, Ida M. — Medical Social Service, Bulletin No. II, published by the Appointment Bureau, Woman’s Educational and Industrial Union, 264 Boylston Street, Boston, Mass., 1912. Journals : American Journal of Nursing — Editorial Office, 45 South Union St., Rochester, N. Y. British Journal of Nursing — Nursing Press Ltd., 4.31 Oxford St., London. 47 Canadian Nurse — Canadian Nurse Publishing Co., 408 McKinnon Building, Toronto, Canada. Public Health Nurse Quarterly, 501 St. Claire St., Cleveland, Ohio. Pacific Coast Journal of Nursing — 721 Call Build¬ ing, New Montgomery and Jesse Sts., San Fran¬ cisco, Cal. The Red Cross Magazine — American Red Cross, Washington, D. C.